Head-To-Toe Assessment (F. Sclerae)

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The sclarae is easily inspected during the assessment of the conjunctivae.

Normal Findings:

·    Sclarae is white in color (anicteric sclera)
·    No yellowish discoloration (icteric sclera).
·    Some capillaries maybe visible.
·    Some people may have pigmented positions.

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• Head-To-Toe Assessment N. Cranial Nerve I (olfactory Nerve) To test the adequacy of function of the olfactory nerve: The client is asked to close his eyes and occlude. The examiner places aromatic and easily distinguish nose. (e.g. coffee). Ask the client to identify the odor. Each side
• Head-To-Toe Assessment (G. Cornea) The cornea is best inspected by directing penlight obliquely from several positions. Normal findings: ·    There should be no irregularities on the surface. ·    Looks smooth. ·    The cornea is clear or transparent. The features of the iris should be fully visible through the cornea. ·    There is a positive corneal reflex.
• Head-To-Toe Assessment (H. Anterior Chamber and Iris) The anterior chamber and the iris are easily inspected in conjunction with the cornea. The technique of oblique illumination is also useful in assessing the anterior chamber. Normal Findings: ·    The anterior chamber is transparent. ·    No noted any visible materials. ·    Color of the iris depends on the person’s race (black, blue, brown or green). ·    From the side
• Head-To-Toe Assessment (E. Conjuctivae) The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look up, down and to each side. When separating the lids, the examiner should exert no NO PRESSURE against the eyeball; rather, the examiner should hold the lids against the ridges of the bony orbit surrounding the eye. In examining
• Head-To-Toe Assessment P. Thorax (Cardiovascular System) Inspection of the Heart The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and heaves or lifts Normal Findings: Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size). There